EWJ June 61 2025 web - Flipbook - Page 40
be made aware of not only common risks but also rare
and serious complications, such as complex regional
pain syndrome (CRPS), nerve damage, or tendon
rupture. CRPS is a challenging condition to explain
in layman’s language and perhaps describing the ongoing symptoms e.g. pain, swelling, stiffness, loss of
function is more appropriate?
ability can be profound. Most cases improve with early
recognition, physiotherapy, and sometimes pharmacological or nerve-targeted treatments, but a small
subset of patients are left with chronic symptoms that
prove resistant to intervention.
From a medicolegal perspective, expert opinion may
be required to comment upon causation, prognosis,
and the appropriateness of treatment provided.
Allegations of delayed diagnosis or failure to treat appropriately may arise, although in many cases the development of CRPS reflects an unfortunate biological
response rather than any demonstrable negligence.
Technical Surgical Errors
Unfortunately technical mistakes during surgery happen - for example, injuring the palmar cutaneous
branch of the median nerve during Open Reduction
Internal Fixation (ORIF) of distal radius fractures, or
selecting screws that are too long and cause tendon
ruptures, are a common source of claims and may
lead to avoidable complications.
The Challenge of Persistent Pain and Disability
Even in the absence of CRPS, a proportion of patients
report ongoing pain, stiffness, weakness or reduced
function following a wrist fracture. The medicolegal
question often posed is whether such symptoms are
attributable to the index injury, or whether they reflect degenerative change, pre-existing pathology, or
non-structural factors.
Inadequate Postoperative Instructions
Failure to advise on immobilisation, rehabilitation
protocols, or warning signs of complications (such as
increasing pain or swelling) may lead to criticism.
Delay in Diagnosis or Referral
In cases of trauma, failing to detect compartment
syndrome or late tendon ruptures may lead to significant functional impairment and successful claims.
Studies suggest that up to 30% of patients may report
some degree of pain or functional limitation a year
after distal radius fracture, particularly in older patients or those with more complex injuries (MacDermid et al., 2003). Factors contributing to prolonged
symptoms include intra-articular involvement, residual deformity, joint stiffness, and psychosocial factors.
Common Complication Key Medicolegal Issue
Nerve injury
Consent and surgical
technique
Tendon injury
Intra-operative error,
missed diagnosis, natural
history
Infection
Documentation of risk and
postoperative care
CRPS
Consent and early
recognition
Nonunion of fracture
Delay in diagnosis or
inappropriate treatment
Importantly, some claimants describe disproportionate pain behaviours, widespread symptoms, or nonanatomical patterns of limitation. Here, the
experienced medicolegal expert must tread carefully,
balancing respect for the patient’s experience with objective clinical assessment and a clear evidence base.
Commenting upon prognosis requires a blend of scientific knowledge, clinical expertise, and realistic appraisal of functional recovery. It is essential to avoid
assuming that structural healing alone guarantees
symptom resolution.
Meticulous record-keeping, clear communication with
patients, and adherence to national guidelines are
essential strategies for mitigating these risks.
Long-Term Disability and Impairment
While many wrist fractures heal with excellent
functional results, a significant proportion of patients
experience ongoing symptoms or limitations. For the
medicolegal expert, assessing long-term impairment
requires a careful balance of clinical knowledge,
patient history, and realistic expectations.
Complex Regional Pain Syndrome (CRPS)
Among the most feared complications following a
wrist fracture is Complex Regional Pain Syndrome
(CRPS). Although its precise cause remains poorly understood, it is thought to relate to an exaggerated inflammatory or autonomic response following injury.
For the medicolegal expert, awareness of CRPS is
crucial, not least because its diagnosis is sometimes
contested, and its prognosis is highly variable.
Persistent stiffness is one of the most frequently
reported problems, particularly affecting pronationsupination (turning the hand palm-down / palm-up)
and wrist extension. Loss of grip strength is also common, especially in those with malunion or tendon adhesions. Even where radiographic healing appears
satisfactory, patients may describe discomfort or functional restriction that impacts their ability to work or
perform domestic tasks.
CRPS is characterised by disproportionate pain,
hypersensitivity, swelling, altered skin colour or temperature, and often significant functional impairment.
The Budapest Criteria provide a validated framework
for diagnosis (Harden et al., 2010), although application in practice is often nuanced and reliant on
clinical judgement.
The distinction between impairment and disability is
worth reiterating; impairment refers to the loss of
physiological function, while disability reflects the impact on day-to-day life. Some individuals with minor
radiological deformity may be profoundly affected
Importantly, the incidence of CRPS following distal
radius fracture is relatively low - in the region of 1-2%
(Dilek et al., 2012) - but its impact on outcome and disEXPERT WITNESS JOURNAL
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